After the implementation of the independent medical speciality of Emergency Medicine in Finland , we have systematically been analyzing and developing our processes and clinical environments [6, 7, 8, 12, 13]. The LWBS rate in our study was low compared to those reported in other studies [14, 15, 16, 17, 18, 19, 20]. Rush hours and longer waiting times coincided with larger numbers of LWBS, even though the total rate was low. Younger patients and patients with minor traumas formed the largest LWBS groups in our study.
Waiting times and rush in the ED are well studied factors associated with increased LWBS rates worldwide [4, 14, 16, 18, 19, 20, 21, 22]. In this study we noticed that when waiting times before being seen by a physician exceeded 75 minutes, mostly during the afternoon hours with more patients, the LWBS rate increased. In some studies, nighttime was a risk factor for LWBS, but this was not apparent in the present study [15, 17, 23].
In our study hospital the proportion of minor traumas among LWBS patients as the reason for attending was rather high (29.4 %), unlike in the studies by Grosgurin et al. (15.0 %) and Parekh et al. (18.3 %) [15, 16]. Younger age groups with a slight male preponderance were over-represented in LWBS in our study, which has also been reported in other studies [14, 15, 24].
In some studies, non-native language speaking background or non-compensable coverage status have been a strong predictor for LWBS [25, 26, 27]. In this study, however, patients whose native language was not Finnish were not overrepresented in LWBS. In Finland, all patients are covered by a municipal tax and the visit fees of EDs are low. Due to the retrospective nature of this study, visit fees as a cause for LWBS were not specifically elicited. However, according to the feedback query system of our ED, visit fees have been a cause of complaints only in sporadic cases. Symptom relief was probably also in some of our patients associated with LWBS as also in some earlier studies [28, 29].
A strength in this study was the large number of total patients studied. We believe that LWBS patients were comprehensively included in the study, since our health records (including the E-book) are well kept and also linked to the municipal payment transactions. The reason for attendance could also be reliably ascertained since on entering the ED every patient was seen by an experienced triage nurse. This yields a trustworthy estimate of the true proportions of different causes for LWBS patients attending the ED. Further, mortality is based on national records in Finland, which are comprehensive and reliable .
The limitations of this single centre study are mainly due to the study design, as it is retrospective. In a prospective study, we would have been able to specify the reasons behind LWBS and waiting times even more accurately than now. On the other hand, patients admitted to a prospective study might be less inclined to leave before seeing a doctor, thus causing a bias. Not all health records in Finland have so far been fully connected to the national database. Therefore, we have no means of knowing about every visit made to private sector healthcare facilities.
Reducing the LWBS rate is an important factor in present-day goal-directed ED management. This improves both patient satisfaction and safety as, although complications are rare, these may occur. Applying lean healthcare interventions or specific fast-track lines for patients improves LWBS rates and throughput in the ED [31, 32, 33]. These suggestions may further improve our results, since the proportion of children and minor traumas suitable for the fast tract policy was high in our LWBS population. To tackle the LWBS problem, we have already implemented an “ED lobby project” aiming to reduce waiting times for ambulatory patients and applying the principles outlined earlier .